HomeMy WebLinkAbout02-0676
REV.1S00 EX + (6-00)
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COMMONWEALTH OF
PENNSYLVANIA
DEPARTMENT OF REVENUE
DEPT. 280601
HARRISBURG, PA 17128.{)601
REV-1500
INHERITANCE TAX RETURN
RESIDENT DECEDENT
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DECEDENT'S NAME (LAST, FIRST. AND MIDDLE INITIAL)
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Shirk Mildred M
DATE OF DEATH (MM-DD-Year)
DATE OF BIRTH (MM-DD-Year)
OFFICIAL USE ONLY
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FILE NUMBER
.1..l..... -....z.. .2.... ..Q.. ..2... Ja .:1.112.
COUNTY CODE YEAR NUMBER
SOCIAL SECURITY NUMBER
167-14-7091
THIS RETURN MUST BE FILED IN DUPLICATE WITH THE
REGISTER OF WILLS
SOCIAL SECURITY NUMBER
o 3. Remainder Return {date of death prior to 12-13-a2)
o 5. Federal Estate Tax Return Required
_ 8. Totar Number of Safe Deposit Boxes
o 11. Ejection to tax under Sec. 9113(A) (AtlachSch0)
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11/01/2001 04/15/1922
(IF APPLICABLE) SURVIVING SPOUSE'S NAME (LAST, FIRST, AND MIDDLE INJTlAl)
PA 17109
OFFICIAL USE ONLY
1 ,g.58.30
9.615.98
3.071.47
79.420.58 i
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00 1. Original Return
o 4. Limited Estate
o 6. Decedent Died Testate (Altal;h copy of Will)
o 9. Litigation Proceeds Received
D 2. Supplemental Retum
o 4a. Future Interest Compromise (date of death after 12-12-82)
o 7. Decedent Maintained a Living Trust (Attach copy ofTrusl)
o 10. Spousal Poverty Credit (dateofdeaihbetween 12-31-91 and 1.1.95)
94.046.33
9.337.28
174.40
9.511.68
84,534.65
!l4,5~4.65
3.804.06
3.804.06
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NAME
Marielle F Hazen
FIRM NAME (If Applicable)
Jan L Brown & Associates
TELEPHONE NUMBER
717-541-5550
845 Sir Thomas Court
Harrisbur
1. Real Estate (Schedule A)
2. Stocks and Bonds (Schedule B)
3. Closely Held Corporation, Partnership or Sore-Proprietorship
4. Mortgages & Notes Receivable (Schedule D)
5. Cash, Bank Deposits & Miscellaneous Personal Property
(Schedule E)
6. Jointly Owned Property (Schedule F)
o Separate Billing Requested
7. Inter-Vivos Transfers & Miscellaneous Non-Probate Property
(Schedule G or L)
8. Totat Gross Assets (total Lines 1-7)
9. Funeral Expenses & Administrative Costs (Schedule H)
10. Debts of Decedent, Mortgage Liabilities, & Liens (Schedule I)
11. Total Deductions (total Lines 9 & 10)
12. Net Value of Estate (Line 8 minus line 11)
13. Charitable and Governmental Bequests/See 9113 Trusts for which an election to tax has not been
made (Schedule J)
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
(9)
(10)
(11)
(12)
(13)
14. Net Vatue Subjectto Tax (Line 12 minus Line 13)
SEE INSTRUCTIONS ON REVERSE SIDE FOR APPLICABLE RATES
(14)
15. Amount of Line 14 taxable at the spousal tax
rate, or transfers under Sec. 9116 (a)(1.2)
x _(15)
84.534.65 X .045 (16)
X .12 (17)
X .15 (18)
(19)
16. Amount of Line 14 taxable at lineal rate
17. Amount of Line 14 taxable at sibling rate
18. Amount of Line 14 taxable at collateral rate
19. Tax Due
20.
CHECK HERE IF YOU ARE REQUESTING A REFUND OF AN OVERPAYMENT
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ece ent's omolete ddress:
STREET ADDRESS
1700 Market Street
CITY I STATE I ZIP
Camp Hill PA 17011
Tax Payments and Credits:
1. Tax Due (Page 1 Line 19)
2. Credits/Payments
A. Spousal Poverty Credit
8. Prior Payments
C. Discounl
(1)
3,804.06
3 500.00
184.21
3. InteresVPenalty if applicable
D. Inlerest
E. Penalty
Total Credits (A + 8 +C)
(2)
3,684.21
T olallnteresVPenaity ( 0 + E ) (3)
4. if Line 2 is grealer Ihan Line 1 + Line 3, enler the difference. This is the OVERPAYMENT.
Check box on Page 1 Line 20 to request a refund (4)
5. If Line 1 + Line 3 is grealer Ihan Line 2, enter Ihe difference. This is the TAX DUE. (5)
A. Enter the inlerest on Ihe lax due. (5A)
8. Enter the lotal of Line 5 + 5A. This is Ihe BALANCE DUE. (58)
Make Check to: REGISTER OF AGENT
119.85
119.85
PLEASE ANSWER THE FOLLOWING QUESTIONS BY PLACING AN "X" IN THE APPROPRIATE BLOCKS
1. Did decedent make a transfer and: Ves No
a. retain the use or income oflhe property transferred; ................................... ................................. ..... 0 IZJ
b. retain the right to designate who shall use the property Iransferred or its income; ............................. .......... 0 IZJ
c. retain a reversionary interest; or ................................... .................. ........................ ................. .... D lXJ
d. receive the promise for life of eilher payments, benefils or care? ............................................................. 0 IZJ
2. If death occurred after December 12,1982, did decedent transfer property within one year of death
without receiving adequate consideration?.............................................................................................. 0 IZJ
3. Did decedent own an 'in Irustfor' or payable upon death bank accounl or securily at his or her dealh? ................. IZJ 0
4. Did decedent own an Individual Retirement Account, annuily, or other non-probale property which
contains a beneficiary designation? ............................................................... ................... IZJ 0
IF THE ANSWER TO ANY OF THE ABOVE QUESTIONS IS YES, YOU MUST COMPLETE SCHEDULE G AND FILE IT AS PART OF THE RETURN,
Under penalties of pe~ury, I declare that I have examined this return, includinQ accompanying schedules and statements, and 10 the best of my knowledge aM belief, it is true, COHect
and complete.
Declaration of preparer other than the pElfSonal representative is based on afllnformalion of which preparer has any knowledge.
SIGNATURE OF PERSON RESPONSIBLE FOR F LING RETURN DATE
, 7-;{ - ~OL
For dates of death on or after July 1, 1994 and before January 1, 1995, the tax rale imposed on Ihe nel value of transfers 10 or for the use of Ihe surviving spouse is 3%
[72 PS. ~9116 (a) (1.1) (i)l.
For dates of death on or after January 1, 1995, Ihe lax rale imposed on the net value of transfers to ortor Ihe use of the surviving spouse is 0% [72 P.S. ~9116 (a) (1.1) (ii)].
The statute does not exemot a transfer to a surviving spouse from tax, and the statutory requirements for disclosure of assets and filing a tax return are still applicable even if
the surviving spouse is the only beneficiary.
For dales of death on or after July 1, 2000:
The tax rate imposed on the net value of transfers from a deceased child twenty-one years of age or younger at death to or for the use of a natural parent, an adoptive parent,
or a stepparent of the child is 0% [72 P.S. ~9116(a)(1.2)].
The tax rate imposed on the net value oflransfers to or for the use oflhe decedent's lineal beneficiaries is 4.5%, except as noted in 72 P.S. ~9116(1.2) [72 P.S. ~9116(a)(1)].
The tax rate imposed on the net value of transfers to or forlhe use of the decedent's siblings is 12% [72 P.S. ~9116(a)(1.3)]. A sibling is defined, under Section 9102, as an
individual who has at least one parent in common wilh the decedent, whether by blood or adoption.
'''~'~''''''",I.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
NT
SCHEDULE B
STOCKS & BONDS
ESTATE OF
Shirk Mildred M
All property jolntly-owned wIIh right 01 survivorship must be disclosed on Schedule F.
FILE NUMBER
ITEM
NUMBER
1.
DESCRIPTION
VALUE AT DATE
OF DEATH
1 ,938~30
MetLife stock; 71 shares@ $27.30
.
TOTAL (Also enter on line 2, Recapitulation) $
(If more space is needed, insert additional sheets of the same size)
1 938.30
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RES1DEN1 DECEDENT
SCHEDULE E
CASH, BANK DEPOSITS, & MISC.
PERSONAL PROPERTY
ESTATE OF FILE NUMBER
Shirk Mildred M
Include the proceeds of litigation and the date the proceecls were received by the estate. All property jointly-owned with the right of survivorship must be disclosed on Schedule F.
ITEM
NUMBER
1.
DESCRIPTION
Transamerica Life Insurance Company
Policy 07250588605; long-term care insurance benefit check
VALUE AT DATE
OF DEATH
2,857.93
2
Transamerica Life Insurance Company
long-term care insurance reimbursement
207.42
4
State Farm
auto insurance premium refund
190.19
5
2001 Federal Income Tax Refund
2,571.00
6
McCullough Funeral Home
overpayment refund
2,641.44
7
1990 Chevrolet Caprice
1,148.00
TOTAL (Also enteron line 5, Recapitulation) $
(If more space IS needed, Insert additional sheets of the same size)
9615.98
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COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE F
JOINTL Y.OWNED PROPERTY
ESTATE OF
Shirk Mildred M
If an asset was made joint within one year of the decedent's date of death, it must be reported on Schedule G.
FILE NUMBER
SURVIVING JOINT TENANT(S} NAME
ADDRESS
RELATIONSHIP TO DECEDENT
A Crystallein Egresits
5512 Edsel Street
Harrisburg, PA 17109
daughter
B Vincent F Shirk
313 Smith's Market Road
Columbia, SC 29212
son
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JOINTLY-OWNED PROPERTY:
LETTER DATE DESCRIPTION OF PROPERTY %OF DATE OF DEATH
ITEM FOR JOINT MADE Include name of fmma! iflstitutioo and hal\k accool'lt number or $\milar klen\itiing number. Attach DATE OF DEATH DECO'S VALUE OF
NUMBER TENANT JOINT deed forjoinUy-held real estate. VALUE OF ASSET INTEREST DECEDENT'S INTEREST
1- A,S 1996 Bank of America; Checking 0060 1006 9227 7,179.02 33.33 2,392.77
2 A 1996 Bank of America; Savings 0032 5258 3580 1,357.40 50. 678.70
TOTAL (Also enter on line 6, Recapitulation) $ 3071.47
(If more space is needed, insert additional sheets of the same size)
'''''''''','',0''.
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE G
INTER-VIVOS TRANSFERS &
MISC. NON-PROBATE PROPERTY
ESTATE OF
Shirk Mildred M
FILE NUMBER
This schedule must be completed and filed if the answer to any of questions 1 through 4 on the reverse side of the REV-1500 COVER SHEET is yes.
DESCRIPTION OF PROPERTY %OF
ITEM INCLUDE THE NAME OFTHE TRANSFEREE. THEIR RElATIONSHIP TO DECEDENT AND THE DATE OF TRANSFER DATE OF DEATH DECO'S EXCLUSION TAXABLE VALUE
NUMBER ATTACH ACOPVOFTHE DEED FOR REAl ESTATE. VALUE OF ASSET INTEREST
(IFAPPLICABLE)
1. MetLife Money Market #403-0189771 916.29 100. 916.29
children Crystallein Egresits, Vincent F Shirk
and Robert L Shirk, beneficiaries
2 Edward Jones Account #616-09566-1-8; securities 52,143.21 100. 52,143.21
transferred equally to children Crystallein Egresits,
Vincent F Shirk and Robert L Shirk upon death
3 Edward Jones Account #616-09566-1-8; CDs 26,361.08 100. 26,361.08
transferred equally to children Crystallein Egresits,
Vincent F Shirk and Robert L Shirk upon death
TOTAL (Also enteron line 7, Recapitulation) $ 79420.58
(If more space is needed, Insert additional sheets of the same size)
''''''''''.'''9''.
COMMONWEALTH OF PENNSYLVANIA
INHERiTANCE TAX RETURN
RESIDENT DECEDENT
SCHEDULE H
FUNERAL EXPENSES &
ADMINISTRATIVE COSTS
ESTATE OF
Shirk Mildred M
FILE NUMBER
Debts of decedent must be reported on Schedule I.
ITEM
NUMBER DESCRIPTION AMOUNT
A FUNERAL EXPENSES:
1. Zimmerman Auer Funeral Home, Inc. 5,082.11
2 Flowers 95.11
3 Clothing 39.98
4 Pastor 200.00
5 Bulletins and tapes 26.01
6 Luncheon 105.00
B. ADMINISTRATIVE COSTS:
1. Personal Representative's Commissions
Name of Personal Representative (5)
Sodal Security Numbe~s) I EIN Number of Personal Representative(s)
Street Address
City State Zip
Year{s) Commission Paid:
2. Attomey Fees Jan L Brown & Associates 1,800.00
3. Family Exemption: (If decedenfs address is not the same as cJaimanfs, attach explanation)
Claimant
Street Address
City State Zip
Relationship of Claimant to Decedent
4. Probate Fees
5. Accountanfs Fees
6. Tax Return Preparer's Fees Frank SOdl, CPA 60.00
7. Vincent F Shirk; travel expense for funeral 602.26
8 Robert L Shirk; travel expense for funeral 644.47
9 Crystallein Egresits; travel expense for funeral 447.14
10 Notary fees 10.00
11 Postage 10.20
12 Reg of Wills, tax return filing fee 15.00
TOTAL (Also enter on line 9, Recapitulation) $ 9337.28
..
(If more space is needed, insert additional sheets of the same size)
REV,"""""'".
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
Shirk Mildred M
SCHEDULE I
DEBTS OF DECEDENT,
MORTGAGE LIABILITIES & LIENS
FILE NUMBER
Include unrelmbursed medical expenses.
ITEM
NUMBER
DESCRIPTION
AMOUNT
174.40
1.
Manor Care Nursing Home
TOTAL (Also enter on line 10, Recapitulation) $
(If more space Is needed, insert additional sheets of the same size)
174.40
REV"513EX'''*
COMMONWEALTH OF PENNSYLVANIA
INHERITANCE TAX RETURN
RESIDENT DECEDENT
ESTATE OF
SCHEDULE J
BENEFICIARIES
FILE NUMBER
C:hid, .Ai rl,~rl .A
RELATIONSHIP TO DECEDENT AMOUNT OR SHARE
NUMBER NAME AND ADDRESS OF PERSON(S) RECEIVING PROPERTY Do Not List Trustee(s) OF ESTATE
I- TAXABLE DISTRIBUTIONS [include OU'r,ilht s~usal d~bibutions, and transfa'" under
Sac. 9116 (a (1. ))
1. Robert Leroy Shirk son 1/3
261 Fox Lake Drive
West Columbia, SC 29170
2 Crystallein Ann Shirk Egresits daughter 1/3
5512 Edsel Street
Harrisburg, PA 17109
3 Vincent Fred Shirk son 1/3
313 Smith's Market Road
Columbia, SC 29212
ENTER DOLLAR AMOUNTS FOR DISTRIBUTIONS SHOWN ABOVE ON LINES 15 THROUGH 18, AS APPROPRIATE, ON REV-1500 COVER SHEET
II. NON-TAXABLE DISTRIBUTIONS:
A. SPOUSAL DISTRIBUTIONS UNDER SECTION 9113 FOR WHICH AN ELECTION TO TAX IS NOT BEING MADE
1.
B. CHARITABLE AND GOVERNMENTAL DISTRIBUTIONS
1.
TOTAL OF PART II - ENTER TOTAL NON-TAXABLE DISTRIBUTIONS ON LINE 13 OF REV-1500 COVER SHEET $
(If more space is needed, insert additional sheets of the same size)
JAN 1. BROWN & ASSOCIATES
ATTORNEYS AND COUNSELORS AT LAW
OLDE ENGLISH GAP
845 S,R THOMAS COURT
SUITE 12
HARRISBURG, PA 17109
EMAIL.jlbassoc@ptd.net
UCERTlFIED ELDER LAW ATTORNEY BY
THE NATIONAL ELDER LAW FOUNDATION
TELEPHONE (717) 541-5550
FACSIMILE (717) 541-9223
'ADMITTED IN PA AND DISTRICT OF COlUMBIA
JAN L. BROWN'
MARIELLE F HAZEN"
July 22, 2002
Register of Wills
Cumberland County Courthouse
One Courthouse Square
Carlisle. PA 17013
Re: Mildred M. Shirk, deceased
Social Security No. 167-14-7091
Gentlemen or Ladies:
Enclosed please find the following items for filing with the Register of Wills:
I. Estate Information Sheet.
2. An original and one copy of the Inheritance Tax Return together with a check in the
amount of$119.85 to cover the additional tax liability shown to be due and a check in the
amount of $ I 5 to cover the filing fee.
3. Copy ofa receipt from the Department of Revenue indicating that a $3,500 prepayment
was made on January 29, 2002. Please be advised that in error the prepayment was
made with the Register of Wills of Dauphin County.
Please time stamp and return our file copies of these documents. A return envelope is
provided.
If you have any questions, feel free to contact this office.
Sincerely,
1xer\clcL F. ~phcvt
Brenda F. Kephart
Legal Assistant
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT.280601
HARRISBURG, PA 17128-0601
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
'*
No.AA 52622 8 REV-l162 EX 111-96)
RECEIVED FROM:
I ACN
ASSESSMENT
CONTROL AMOUNT
JAN L. BROWN, ESQUIRE NUMBER
845 SIR THOMAS COURT, SUITE 12
HARRISBURG, PA. 17109 101 3.500.00
FOLD HERE
ESTATE INFORMATION: I FOlD HERE
FILE NUMBER
22-02-0109
NAME OF DECEDENT (LAST) (FIRST) (MI)
8HIPJ( MILDRED M.
DATE OF PAYMENT
1-30-2002
POSTMARK DATE
1-29-2002
COUNTY
DAUPHIN TOTAL AMOUNT PAID 3.500.00
DATE OF DEATH
11-1-2001 ~).
REMARKS RECEIVED BY '" ._.~ . .'"
S8 # 167-14-7091
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SEAL
TAXPAYER
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT. 280601
HARRISBURG, PA 17128-0601
REV-1162 EX(11-96)
RECEIVED FROM:
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
NO. CD 001451
DUPLlCA TE
HAZEN MARIELLE F
845 SIR THOMAS COURT
HARRISBURG, PA 17109
__nnn fold
ESTATE INFORMATION: SSN: 167-14-7091
FILE NUMBER: 2102-0676
DECEDENT NAME: SHIRK MILDRED M
DATE OF PAYMENT: 07/26/2002
POSTMARK DATE: 07/23/2002
COUNTY: CUMBERLAND
DATE OF DEATH: 11/01/2001
ACN
ASSESSMENT
CONTROL
NUMBER
AMOUNT
101 I $119.85
I
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TOTAL AMOUNT PAID:
$119.85
REMARKS:
CHECK# 7086
SEAL
INITIALS: JA
RECEIVED BY:
REGISTER OF WILLS
MARY C. LEWIS
REGISTER OF WILLS
60~H \fd '8HnSSIHHVH
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dV8 HSIl8N3 3010
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPARTMENT 280601
HARRISBURG, PA 17128-0601
Telephone
717787-3930
AUGUST 26. 2002
Dear Register of Wills:
Re: Estate of MILDRED SHIRK
File Number: 2201-1184
County: DAUPHIN
Date of Death: 11-01-2001
The subject decedent legally resided in CUMBERLAND County as of the date of death.
Accordingly, you are authorized to cancel file number 2201-1184. All matters concerning this
estate should be maintained under Cumberland COUNTY File Number 2102-0676.
All original Inheritance Tax documents for the subject decedent should be forwarded to
the CUMBERLAND County Register of Wills; however. you may wish to retain a copy. including
photocopies of all receipts for the collection of Inheritance Taxes in the subject estate which
have been issued by your office.
Please contact me at the telephone number above if you have any questions.
~in rei,
. 11,1,1. ,? . /1hl
. ~'"
Je rey D. HOllenbush, Supervisor.
Document Processing Unit
Inheritance Tax Division
RECEIVED FROM:
ACN
I ASSESSMENT AMOUNT
CONTROL
JAN L. BROWN, ESQUIRE NUMBER
845 SIll. THOMAS COURT, SUITE 12
HARRISBURG, PA. 17109 101 3.500.00
FOLD HERE FOLD HERE
ESTATE INFORMATION: I
FILE NUMBER
22-02-0109
NAME OF DECEDENT (LAST) (FIRST) (MI)
SlURK MILDRED M.
DATE OF PAYMENT
1-30-2002
POSTMARK DATE
1-29-2002
COUNTY 3,500.00
DAUPlUN TOTAL AMOUNT PAID
DATi.OF DEATH
1-1-2001 \~~ \.J.\ \.
REM RK RECEIVED BY " "~\::::, -,
167-14-7091 :\
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COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
BUREAU OF INDIVIDUAL TAXES
DEPT.280601
HARRISBURG, PA 17128-0601
PENNSYLVANIA
INHERITANCE AND ESTATE TAX
OFFICIAL RECEIPT
.L
REGISTER OF WILLS
-
'*
No.AA 526228 REV-1162 EX (11-96)
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BUREAU OF INDIVIDUAL TAXES
INHERITANCE TAX DIVISION
DEPT. 280601
HARRISBURG I PA 17128-0601
COMMONWEALTH OF PENNSYLVANIA
DEPARTMENT OF REVENUE
NOTICE OF INHERITANCE TAX
APPRAISEMENT, ALLOWANCE OR DISALLOWANCE
OF DEDUCTIONS AND ASSESSMENT OF TAX
MARIELLE F HAZEN
JAN L BROWN & ASSOCS
845 SIR THOMAS CT
HBG PA 17109
DATE
ESTATE OF
DATE OF DEATH
FILE NUMBER
COUNTY
ACN
09-10-2002
SHIRK
11-01-2001
21 02-0676
CUMBERLAND
101
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REY-l!i47EXAFP(Ol-OU
MILDRED
M
Allount Rellitted
MAKE CHECK PAYABLE AND REMIT PAYMENT TO:
REGISTER OF WILLS
CUMBERLAND CO COURT HOUSE
CARLISLE, PA 17013
CUT ALONG THIS LINE ~ RETAIN LOWER PORTION FOR YOUR RECORDS ~
REV=is4TEx--AFP--fiiFiirfr-tlii'rYcE--oF-YNHE'ifiTAifcrrA"infppiiXisEi'-EtlT~--Ai:.l-owAiicE-'i'-R--------------m
DISALLOWANCE OF DEDUCTIONS AND ASSESSMENT OF TAX
ESTATE OF SHIRK MILDRED M FILE NO. 21 02-0676 ACN 101 DATE 09-10-2002
TAX RETURN WAS: (X) ACCEPTED AS FILED
CHANGED
RESERVATION CONCERNING FUTURE INTEREST - SEE REVERSE
APPRAISED VALUE OF RETURN BASED ON: ORIGINAL RETURN
1. Real Estate (Schedule AJ
2. Stocks end Bonds (Schedule B)
3. Closely Held stock/Partnership Interest (Schedule C)
4. Mortgages/Notes Receivable {Schedule DJ
5. Cash/Bank Deposits/Misc. Personal Property (Schedule EJ
6. Jointly Owned Property (Schedule fJ
7. Transfers (Schedule G)
8. Total Assets
ll)
(2)
(3)
(4)
(5)
(6)
(7)
APPROVED DEDUCTIONS AND EXEMPTIONS:
9. Funeral Expenses/Ad... Costs/Misc. Expenses (Schedule H)
10. Debts/Mortgage Liabilities/Liens (Schedule I)
11. Total Deductions
12. Net Value of Tax Return
13. Charitable/Governmental Bequests; Non-elected 9113 Trusts (Schedule J)
14. Net Value of Estate Subject to Tax
(9)
llO)
.00
1.938.30
.00
.00
9,615.98
3,071.47
79.420.58
(8)
9,337.28
NOTE: I~ an assessment was issued previously, lines 14, 15 and/or 16, 17, 18 and 19 will
re~lect ~igures that include the total o~ ALL returns assessed to date.
ASSESSMENT OF TAX:
15. Amount of Line 14 at Spousal rate (15)
16. Amount of Line 14 taxable at Lineal/Class A rate (16)
17. Amount of Line 14 at Sibling rate (17)
18. Amount of Line 14 taxable at Collateral/Class B rate (18)
19. Principal Tax Due
.00 X 00 = .00
84,534.65 X 045 = 3,804.06
.00 X 12 = .00
.00 X 15 = .00
ll9)= 3,804.06
174.40
ll1l
(12)
(13)
ll4)
NOTE: To insure proper
credit to your account,
submit the upper portion
of this form with your
tax payment.
94,046.33
9 .~1l 68
84,534.65
.00
84,534.65
TAX CREnnS:
'+J AMOUNT PAID
DATE NUMBER INTEREST/PEN PAID I )
01-29-2002 AA526228 184.21 3,500.00
07-23-2002 CDOO1451 .00 119.85
TOTAL TAX CREDIT 3,804.06
BALANCE OF TAX DUE .00
INTEREST AND PEN. .00
TOTAL DUE .00
. IF PAID AFTER DATE INDICATED, SEE REVERSE
FOR CALCULATION OF ADDITIONAL INTEREST.
I IF TOTAL DUE IS LESS THAN $1, NO PAYMENT IS REQUIRED.
IF TOTAL DUE IS REFLECTED AS A "CREDIT" ICR), YOU MAY BE DUE
A REFUND. SEE REVERSE SIDE OF THIS FORM FOR INSTRUCTIONS.)